RF Ablation of AF First Line Treatment: Pro

Cairo Heart Rhythm 2010

Dipen Shah MD,Hopital Cantonal Universitaire de Geneve,

Switzerland

n= 635 procedures

Procedure time 187±52 minRF time 43±20 minProcedures/pt 1.3Complications Embolic 2* (0.3%) Tamponade 6 (0.9%) Gastroparesis 2 (0.3%) PV stenosis (asymptomatic) 2 (0.3%)

Puncture site 6 (1%) Hemothorax 1 (0.1%)

Sex 393 M/94F

Age 57±9 yrsParoxysmal AF 349 (72%)Pers/Permanent AF 138 (28%)

LA size 4.2±0.7 cm

Heart disease 85 (17%) LVEF 82 (17%)CVA 39 (8%)

Patient characteristics Procedural characteristics

Afib Ablation at the HUG: 2002-2008487 patients

Complication Type

No. of Patients

% of Patients

For all procedures (n=8745)Death 4 0.05

Tamponade 107 1.22

For LA procedures (n=7154)

Stroke 20 0.28TIA 47 0.66

Total 524 5.9

Complication Type

No. of Patient

s

% of Patient

s

Death 0 0Tamponade/Pericardial effusion

6/8 0.6/0.8

Stroke/TIA 5 0.5

Hemorrhagic complications 12 1.2

Total 40 3.9

n=1011 patients10 centers

2005

n=9075 patients100 centers

2002

Fewer Complications: Learning Curve Effect

Wazni et al, JAMA 2005, 293, 2634-2640

32 patients – PVI35 patients – AAD One year FUP:PVI: 87% AF freeAAD: 37% AF free

Antiarrhythmic drugs vs. PVI for rhythm control

• Results with drugs do not depend upon experience!• For antiarrhythmic drug treatment

• Initial episodes of AF• Unsuitable or poor candidates for ablation• Failure of ablation• ?Asymptomatic AF

• Unsuitable for antiarrhythmic drug treatment• Concomitant bradycardia• Other side effects

• Heart failure, syncope or embolic complications favour a more effective nonpharmacologic treatment

RF

AAD

Type of AADs (Drug group)

0

20

40

60

80

100

1 2 3 4

AAD Class (Vaughan-Williams)

% Type of AADs(Drug group)

n= 53

n= 59

AF Progression• Kerr et al, Am Heart J 2005; 149: 489-496

8.6% & 24.7% progression to chronic AF by 1 & 5 years• Jahangir et al, Circulation 2007; 115: 3050-56

31% progression to permanent AF over 25±10 yrs f-up.• Nieuwlaat et al, Eur Heart J 2008; 29:1181-9

Within 1 yr, 20% PAF progressed Within 1 yr, 30% persistent became permanent AF

Initial AF • AF with reversible causes : pneumonia,

hyperthyroidism, pericarditis, recent heart surgery

• Rhythm control preferred initial therapy in highly symptomatic patients

• First episode of AF may not recur for a long time..even without specific treatment

• Anticoagulation should not be hastily discontinued after restoration of sinus rhythm – continue for 12 rather than 4 weeks.

Catheter Ablation as First-Line Treatment of AFib

• Young very symptomatic patients • who refuse long

term AADs and anticoagulation

• Young patients with parox/persistent AF and sinus node dysfunction

• Endurance athletes with paroxysmal AF

• Brady-tachy syndrome and parox AF

• Parox AF with Brugada pattern ECG/Brugada syndrome

Padanilam, et al, Circulation 2005, 112, 1223-9

European Heart Journal doi:10.1093/eurheartj/ehq278ESC GUIDELINES 2010

Recommendations Class Level Ref

Catheter ablation of AF may be considered prior to antiarrhythmic drug therapy in symptomatic patients despite adequate rate control with paroxysmal symptomatic AF and no significant underlying heart disease

IIb B 131